101
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Vu LT, Duc NM, Tra My TT, Bang LV, Luu DT, Thong PM. The first case of Trichophyton spp. pneumonia reported in Vietnam. Respir Med Case Rep 2021; 32:101371. [PMID: 33680802 PMCID: PMC7910523 DOI: 10.1016/j.rmcr.2021.101371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 11/20/2022] Open
Abstract
A respiratory fungal infection is a severe clinical problem caused by endemic or opportunistic fungi. Although pulmonary fungal infections may be associated with no symptoms, the patient may also present with cough, fever, chest pain, and hemoptysis. Trichophyton spp., a dermatophyte fungus, is a dermatologic pathogen and can cause a deep, sometimes fatal infection. Here, we report the first case of a deep Trichophyton spp. Infection in Vietnam and possibly the first case of Trichophyton spp. pneumonia in the literature, which responded completely to medical therapy. This article highlights the epidemiology of fungal lung infections and describes the clinical approach for when to suspect and how to diagnose this disease.
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Affiliation(s)
- Le Thuong Vu
- Department of Internal Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Nguyen Minh Duc
- Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Viet Nam.,Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Viet Nam.,Department of Radiology, Ha Noi Medical University, Ha Noi, Viet Nam
| | - Thieu-Thi Tra My
- Department of Radiology, Ha Noi Medical University, Ha Noi, Viet Nam
| | - Luong Viet Bang
- Department of Pathology, Tam Anh General Hospital, Ha Noi, Viet Nam
| | - Doan Tien Luu
- Department of Radiology, Ha Noi Medical University, Ha Noi, Viet Nam
| | - Pham Minh Thong
- Department of Radiology, Ha Noi Medical University, Ha Noi, Viet Nam
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102
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Sharma S, Thakare P, Utpat K, Desai U. Hydatid disease with Aspergilloma: A unique case report. Monaldi Arch Chest Dis 2021; 91. [PMID: 33567817 DOI: 10.4081/monaldi.2021.1549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/15/2020] [Indexed: 11/23/2022] Open
Abstract
The coexisting presence of hydatid disease with aspergillus colonization is a rare finding. The 20-year-old presented with symptoms of hemoptysis with past history of tuberculosis. On further evaluation, the patient was diagnosed as a case of aspergilloma and managed conservatively. After one year of presenting with similar complaints, the patient was turned out to be hydatid disease with aspergillus colonization on the basis of clinic-radiological and bronchoscopic evaluation. Till now only a few case reports have been reported. We report a unique case report of a similar presentation.
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Affiliation(s)
- Sandeep Sharma
- Department of Pulmonary Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai.
| | - Parikshit Thakare
- Department of Pulmonary Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai.
| | - Ketaki Utpat
- Department of Pulmonary Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai.
| | - Unnati Desai
- Department of Pulmonary Medicine, Topiwala National Medical College and BYL Nair Hospital, Mumbai.
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103
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Dameron M, Horowitz M, Gupta N, Abi Hatem N. When to consider Pneumocystis jirovecii prophylaxis in HIV-negative patients. JAAPA 2021; 34:24-26. [PMID: 33470717 DOI: 10.1097/01.jaa.0000723924.04331.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Clinicians should be aware of the risk of opportunistic infections in patients who are immunocompromised. Opportunistic infections such as Pneumocystis jirovecii commonly are associated with HIV/AIDS, but less commonly considered in patients receiving immunosuppressive and/or immunomodulating therapies. This case report focuses on the management of an opportunistic infection in an HIV-negative patient on immunosuppressive medications for lymphoma and exacerbation of pulmonary fibrosis.
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Affiliation(s)
- Matthew Dameron
- At the Salem (Va.) Veterans Affairs Medical Center, Matthew Dameron practices in the Department of Medicine, and Mitchell Horowitz , Neeraj Gupta , and Nathalie Abi Hatem practice in the Department of Pulmonary and Critical Care Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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104
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Cass L, Murray A, Davis A, Woodward K, Albayaty M, Ito K, Strong P, Ayrton J, Brindley C, Prosser J, Murray J, French E, Haywood P, Wallis C, Rapeport G. Safety and nonclinical and clinical pharmacokinetics of PC945, a novel inhaled triazole antifungal agent. Pharmacol Res Perspect 2021; 9:e00690. [PMID: 33340279 PMCID: PMC7749516 DOI: 10.1002/prp2.690] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/18/2022] Open
Abstract
PC945 is a novel antifungal triazole formulated for nebulized delivery to treat lung Aspergillus infections. Pharmacokinetic and safety profiles from nonclinical studies and clinical trials in healthy subjects, and subjects with mild asthma were characterized. Toxicokinetics were assessed following daily 2-hour inhalation for 14 days. Potential for drug-drug interactions was evaluated using pooled human liver microsomes. Clinical safety and pharmacokinetics were assessed following (a) single inhaled doses (0.5-10 mg), (b) 7-day repeat doses (5 mg daily) in healthy subjects; (c) a single dose (5 mg) in subjects with mild asthma. Cmax occurred 4 hours (rats) or immediately (dogs) after a single dose. PC945 lung concentrations were substantially higher (>2000-fold) than those in plasma. PC945 only inhibited CYP3A4/5 substrate metabolism (IC50 : 1.33 µM [testosterone] and 0.085 µM [midazolam]). Geometric mean Cmax was 322 pg/mL (healthy subjects) and 335 pg/mL (subjects with mild asthma) 4-5 hours (median tmax ) after a single inhalation (5 mg). Following repeat, once daily inhalation (5 mg), Day 7 Cmax was 951 pg/mL (0.0016 µM) 45 minutes after dosing. Increases in Cmax and AUC0-24h were approximately dose-proportional (0.5-10 mg). PC945 administration was well tolerated in both healthy subjects and subjects with mild asthma. Treatment-emergent adverse events were mild/moderate and resolved before the study ended. No clinically significant lung function changes were observed. PC945 pharmacokinetics translated from nonclinical species to humans showed slow absorption from lungs and low systemic exposure, thereby limiting the potential for adverse side effects and drug interactions commonly seen with systemically delivered azoles.
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Affiliation(s)
| | | | | | | | - Muna Albayaty
- Parexel Early Phase Clinical Unit Level 7Northwick Park HospitalHarrowUK
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105
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Ng KL, Huan N, Nasaruddin MZ, Muhammad NA, Daut UN, Abdul Rahaman JA. Pulmonary mucormycosis masquerading as endobronchial tumour in an immunocompetent pregnant young lady. Respirol Case Rep 2021; 9:e00704. [PMID: 33364028 PMCID: PMC7756165 DOI: 10.1002/rcr2.704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/30/2020] [Accepted: 12/03/2020] [Indexed: 11/11/2022] Open
Abstract
Pulmonary mucormycosis is a rare but rapidly progressing and life-threatening fungal infection, usually affecting immunocompromised patients. We report a case of a previously healthy young lady who presented with prolonged cough, weight loss, and haemoptysis. Imaging showed left hilar mass with infiltration into the left main bronchus and concurrent mediastinal lymphadenopathy. Flexible bronchoscopy revealed an endobronchial mass occluding the left main bronchus. Tumour debulking was performed using rigid bronchoscopy with cryoprobe and snares. Histopathological examination revealed inflamed tissue with fungal organism. Fungal polymerase chain reaction (PCR) confirmed Rhizopus microsporus. She was treated with two weeks of intravenous amphotericin-B with complete clinical and radiological resolution.
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Affiliation(s)
- Khai Lip Ng
- Department of PulmonologySerdang HospitalKajangMalaysia
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106
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Abstract
Coccidioidomycosis is a fungal infection of the Western hemisphere that is endemic to the soil in areas with limited rainfall. Human and animal infections result with inhalation of arthroconidia. Most often, this is an asymptomatic event. When illness occurs, it is primarily a pneumonic presentation. A small minority of infections eventuate in disseminated disease. Predominately, this presents as meningitis or osteoarticular or integumentary disease. Treatment may not be required for the mildest illness. Azoles are commonly prescribed. Severe infections may require amphotericin B.
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Affiliation(s)
- Royce H Johnson
- Infectious Diseases, Kern Medical Center, Bakersfield, California, USA.,Valley Fever Institute, Bakersfield, California, USA
| | - Rupam Sharma
- Infectious Diseases, Kern Medical Center, Bakersfield, California, USA.,Valley Fever Institute, Bakersfield, California, USA
| | - Rasha Kuran
- Infectious Diseases, Kern Medical Center, Bakersfield, California, USA.,Valley Fever Institute, Bakersfield, California, USA
| | - Isabel Fong
- Infectious Diseases, Kern Medical Center, Bakersfield, California, USA.,Valley Fever Institute, Bakersfield, California, USA
| | - Arash Heidari
- Infectious Diseases, Kern Medical Center, Bakersfield, California, USA .,Valley Fever Institute, Bakersfield, California, USA
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107
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Rates of Prophylaxis Among Pneumocystis jirovecii Pneumonia Cases Attributable to High-dose Steroid Therapy. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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108
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Choi W, Yang AX, Sieve A, Kuo SH, Mudalagiriyappa S, Vieson M, Maddox CW, Nanjappa SG, Lau GW. Pulmonary Mycosis Drives Forkhead Box Protein A2 Degradation and Mucus Hypersecretion through Activation of the Spleen Tyrosine Kinase-Epidermal Growth Factor Receptor-AKT/Extracellular Signal-Regulated Kinase 1/2 Signaling. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:108-130. [PMID: 33069717 PMCID: PMC7786105 DOI: 10.1016/j.ajpath.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/08/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
Pulmonary mycoses are difficult to treat and detrimental to patients. Fungal infections modulate the lung immune response, induce goblet cell hyperplasia and metaplasia, and mucus hypersecretion in the airways. Excessive mucus clogs small airways and reduces pulmonary function by decreasing oxygen exchange, leading to respiratory distress. The forkhead box protein A2 (FOXA2) is a transcription factor that regulates mucus homeostasis in the airways. However, little is known whether pulmonary mycosis modulates FOXA2 function. Herein, we investigated whether Blastomyces dermatitidis and Histoplasma capsulatum-infected canine and feline lungs and airway epithelial cells could serve as higher animal models to examine the relationships between fungal pneumonia and FOXA2-regulated airway mucus homeostasis. The results indicate that fungal infection down-regulated FOXA2 expression in airway epithelial cells, with concomitant overexpression of mucin 5AC (MUC5AC) and mucin 5B (MUC5B) mucins. Mechanistic studies reveal that B. dermatitidis infection, as well as β-glucan exposure, activated the Dectin-1-SYK-epidermal growth factor receptor-AKT/extracellular signal-regulated kinase 1/2 signaling pathway that inhibits the expression of FOXA2, resulting in overexpression of MUC5AC and MUC5B in canine airway cells. Further understanding of the role of FOXA2 in mucus hypersecretion may lead to novel therapeutics against excessive mucus in both human and veterinary patients with pulmonary mycosis.
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Affiliation(s)
- Woosuk Choi
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Alina X Yang
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Aaron Sieve
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Shanny H Kuo
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Srinivasu Mudalagiriyappa
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Miranda Vieson
- Veterinary Diagnostic Laboratory, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois; Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Carol W Maddox
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois; Veterinary Diagnostic Laboratory, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Som G Nanjappa
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois
| | - Gee W Lau
- Department of Pathobiology, College of Veterinary Medicine, University of Illinois at Urbana-Champaign, Urbana, Illinois.
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109
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Sankar J, Varadaraju S, Khandelwal P, Hari P. Multiple opportunistic infection-associated hemophagocytic lymphohistiocytosis in nephrotic syndrome: A case report. JOURNAL OF PEDIATRIC CRITICAL CARE 2021. [DOI: 10.4103/jpcc.jpcc_64_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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110
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Mantadakis E. Pneumocystis jirovecii Pneumonia in Children with Hematological Malignancies: Diagnosis and Approaches to Management. J Fungi (Basel) 2020; 6:jof6040331. [PMID: 33276699 PMCID: PMC7761543 DOI: 10.3390/jof6040331] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 12/21/2022] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that mostly affects children with suppressed cellular immunity. PJP was the most common cause of infectious death in children with acute lymphoblastic leukemia prior to the inclusion of cotrimoxazole prophylaxis as part of the standard medical care in the late 1980s. Children with acute leukemia, lymphomas, and those undergoing hematopoietic stem cell transplantation, especially allogeneic transplantation, are also at high risk of PJP. Persistent lymphopenia, graft versus host disease, poor immune reconstitution, and lengthy use of corticosteroids are significant risk factors for PJP. Active infection may be due to reactivation of latent infection or recent acquisition from environmental exposure. Intense hypoxemia and impaired diffusing capacity of the lungs are hallmarks of PJP, while computerized tomography of the lungs is the diagnostic technique of choice. Immunofluorescence testing with monoclonal antibodies followed by fluorescent microscopy and polymerase chain reaction testing of respiratory specimens have emerged as the best diagnostic methods. Measurement of (1-3)-β-D-glucan in the serum has a high negative predictive value in ruling out PJP. Oral cotrimoxazole is effective for prophylaxis, but in intolerant patients, intravenous and aerosolized pentamidine, dapsone, and atovaquone are effective alternatives. Ιntravenous cotrimoxazole is the treatment of choice, but PJP has a high mortality even with appropriate therapy.
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Affiliation(s)
- Elpis Mantadakis
- Department of Pediatrics, Hematology/Oncology Unit, University General Hospital of Alexandroupolis, Democritus University of Thrace, 68 100 Alexandroupolis, Thrace, Greece
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111
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Bateman M, Oladele R, Kolls JK. Diagnosing Pneumocystis jirovecii pneumonia: A review of current methods and novel approaches. Med Mycol 2020; 58:1015-1028. [PMID: 32400869 PMCID: PMC7657095 DOI: 10.1093/mmy/myaa024] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/13/2020] [Accepted: 05/07/2020] [Indexed: 12/13/2022] Open
Abstract
Pneumocystis jirovecii can cause life-threatening pneumonia in immunocompromised patients. Traditional diagnostic testing has relied on staining and direct visualization of the life-forms in bronchoalveolar lavage fluid. This method has proven insensitive, and invasive procedures may be needed to obtain adequate samples. Molecular methods of detection such as polymerase chain reaction (PCR), loop-mediated isothermal amplification (LAMP), and antibody-antigen assays have been developed in an effort to solve these problems. These techniques are very sensitive and have the potential to detect Pneumocystis life-forms in noninvasive samples such as sputum, oral washes, nasopharyngeal aspirates, and serum. This review evaluates 100 studies that compare use of various diagnostic tests for Pneumocystis jirovecii pneumonia (PCP) in patient samples. Novel diagnostic methods have been widely used in the research setting but have faced barriers to clinical implementation including: interpretation of low fungal burdens, standardization of techniques, integration into resource-poor settings, poor understanding of the impact of host factors, geographic variations in the organism, heterogeneity of studies, and limited clinician recognition of PCP. Addressing these barriers will require identification of phenotypes that progress to PCP and diagnostic cut-offs for colonization, generation of life-form specific markers, comparison of commercial PCR assays, investigation of cost-effective point of care options, evaluation of host factors such as HIV status that may impact diagnosis, and identification of markers of genetic diversity that may be useful in diagnostic panels. Performing high-quality studies and educating physicians will be crucial to improve the rates of diagnosis of PCP and ultimately to improve patient outcomes.
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Affiliation(s)
- Marjorie Bateman
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
| | - Rita Oladele
- Department of Medical Microbiology and Parasitology, College of Medicine, University of Lagos, Nigeria
| | - Jay K Kolls
- Center for Translational Research in Infection and Inflammation, Tulane University School of Medicine, New Orleans, LA 70122, USA
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112
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Anderson JL, Frost HM, Meece JK. Spontaneous resolution of blastomycosis symptoms caused by B. dermatitidis. Med Mycol Case Rep 2020; 30:43-45. [PMID: 33150126 PMCID: PMC7599114 DOI: 10.1016/j.mmcr.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022] Open
Abstract
Given the propensity of blastomycosis to disseminate or reoccur and the inability to predict which infections will experience severe manifestations, nearly all cases of blastomycosis are treated. Although, spontaneous resolution of symptoms is referred to generally in the literature, to our knowledge an individual case of this has not been previously reported. We report the spontaneous resolution of blastomycosis symptoms in a 40 year-old Caucasian male.
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Affiliation(s)
- Jennifer L. Anderson
- Integrated Research and Development aLaboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, 54449, USA
- Corresponding author.
| | - Holly M. Frost
- Denver Health and Hospital Authority, Department of Pediatrics, Denver, CO, 80204, USA
- Denver Health and Hospital Authority, Office of Research, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, 80045, USA
| | - Jennifer K. Meece
- Integrated Research and Development aLaboratory, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, WI, 54449, USA
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113
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Zhang H, Wang K, Chen H, Sun L, Wang Z, Fei S, Tan R, Gu M. The Double-Edged Sword of Immunosuppressive Therapy in Kidney Transplantation: A Rare Case Report of Pulmonary Mucormycosis Post-Transplant and Literature Review. Front Med (Lausanne) 2020; 7:500. [PMID: 33072770 PMCID: PMC7538690 DOI: 10.3389/fmed.2020.00500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/21/2020] [Indexed: 12/14/2022] Open
Abstract
Immunosuppressive therapy is improving the graft survival of kidney transplant recipients and increasing the potential risk of infection. Pulmonary mucormycosis is a rare post-operative infection complication characterized with rapid deterioration and high mortality. In this case, a 33-year-old patient underwent a kidney transplantation with regular immunosuppressive therapy. Soon, 38 days post-transplant, pulmonary patchy shadows can be seen in the radiological examination and rounded into a large cavity formation with splenic rupture 25 days later. The diagnosis of mucormycosis was confirmed by lung biopsy and spleen histopathology. This case is a reminder that early diagnosis is imperative, meanwhile, rational antifungal therapy, timely elimination of immunosuppressants, and alternatively, abandoning the graft should be prudently assessed in the treatment of mucormycosis.
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Affiliation(s)
- Hengcheng Zhang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Transplantation Research Center, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Ke Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Chen
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Li Sun
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zijie Wang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shuang Fei
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ruoyun Tan
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Min Gu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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114
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Hernández S, Puerto MP, Gomez C. Neumonía por Pneumocystis Jirovecii en paciente adolescente inmunosuprimido no VIH positivo: Un reporte de caso. INFECTIO 2020. [DOI: 10.22354/in.v25i1.911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
La neumonía en el paciente inmunocomprometido es un reto diagnóstico al cual el clínico se enfrenta cada vez con más frecuencia , al momento de hablar de infiltrados en vidrio esmerilado es menester tener siempre en cuenta la posibilidad de neumonía por Pneumocystis Jirovecii, que por mucho tiempo se pensó como una enfermedad propia del huésped inmunosuprimido con VIH, a través del tiempo se ha manifestado en pacientes con trasplantes de órgano sólido y de precursores hematopoyéticos, asociado a autoinmunidad, al uso crónico de corticoesteroides y más recientemente al uso de terapia biológicas. La descripción de esta enfermedad y sus métodos diagnósticos en huéspedes inmunosuprimidos no VIH no es del todo claro, sabemos que el tratamiento de elección en estos casos es el trimetropin-sulfametoxazol (TMP-SMX) el cual no cuenta con evidencia de alta calidad al momento de plantear una dosis ni un tiempo de duración establecidos. Presentamos el caso de un paciente con diagnóstico de glomerulonefritis por enfermedad de cambios mínimos corticodependiente y quien desarrolló neumonía por Pneumocystis Jirovecii confirmada por histopatología quien recibió tratamiento y tuvo un desenlace positivo.
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115
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Pike-Lee T, Syed S, Willis MA, Li Y. Pneumocystis jirovecii Pneumonia in Neurologic Disorders: Is Prophylaxis Necessary? Neurol Clin Pract 2020; 11:242-248. [PMID: 34484891 DOI: 10.1212/cpj.0000000000000923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/07/2020] [Indexed: 11/15/2022]
Abstract
Background The incidence of Pneumocystis jirovecii pneumonia (PJP) in patients with underlying neurologic conditions is not well established, and the necessity of PJP prophylaxis for immunocompromised patients with neurologic disorders is uncertain. Methods Single-center retrospective analysis of non-HIV PJP patients at a tertiary referral center from 2007 to 2016 to determine the incidence of PJP in patients with primary neurologic disorders. Results The study included 142 patients with PJP without HIV. Twenty patients had primary neurologic diagnoses, and 122 had non-neurologic conditions. Associated neurologic diagnoses included brain malignancies (N = 14), myasthenia gravis (MG) (N = 2), myopathy (N = 2), neuromyelitis optica (NMO) (N = 1), and CNS vasculitis (N = 1). Estimated incidences of PJP were 0.7% for patients with NMO and 0.3% for patients with MG for the 10-year study period, whereas 4.6% of patients with NMO and 3.8% of patients with MG were placed on PJP prophylaxis. A survey of 24 neurologists who prescribe immunotherapy or chemotherapy confirmed an infrequent occurrence of PJP in their practice. Malignancy or parenchymal organ failure was present in 90% of neurologic patients with PJP, and coexisting infections occurred in 45%. Conclusions The overall incidence of PJP in patients with non-neoplastic neurologic disorders is exceedingly low, raising doubt about the value of routine PJP prophylaxis in neurologic patients outside neuro-oncology. PJP infection occurs frequently in patients with malignancy or parenchymal organ failure, indicating that overall health status may serve as a predisposing factor for PJP.
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Affiliation(s)
- Tiffany Pike-Lee
- Department of Neurology, Neurological Institute, Cleveland Clinic, OH. Dr. Willis is now with Department of Neurology, University of Mississippi Medical Center, Jackson
| | - Sana Syed
- Department of Neurology, Neurological Institute, Cleveland Clinic, OH. Dr. Willis is now with Department of Neurology, University of Mississippi Medical Center, Jackson
| | - Mary Alissa Willis
- Department of Neurology, Neurological Institute, Cleveland Clinic, OH. Dr. Willis is now with Department of Neurology, University of Mississippi Medical Center, Jackson
| | - Yuebing Li
- Department of Neurology, Neurological Institute, Cleveland Clinic, OH. Dr. Willis is now with Department of Neurology, University of Mississippi Medical Center, Jackson
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116
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Iqbal N, Ammar M, Irfan M, Jabeen K. Trichosporon Species and Fusarium Species as a Cause of Empyema Thoracis in a Diabetic Patient. Cureus 2020; 12:e8973. [PMID: 32775055 PMCID: PMC7402428 DOI: 10.7759/cureus.8973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Of late, fungal infections are increasingly being recognized in diabetic patients. Here we present a case of polymicrobial fungal empyema due to Trichosporon species and Fusarium species developed after community-acquired pneumonia in a diabetic patient. Trichosporon species are basidiomycetous yeast and Fusarium species are soil saprophytes with a worldwide distribution. Fungal empyema cases are rare and are mostly caused by Aspergillus and Candida species. Polymicrobial fungal empyema with Trichosporon species and Fusarium species has not been reported previously. Our patient was successfully treated with antifungal therapy. This case highlights that fungal empyema should be considered in diabetic patients especially if they are not responding to antibiotics.
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Affiliation(s)
- Nousheen Iqbal
- Section of Pulmonary and Critical Care Medicine, Aga Khan University, Karachi, PAK.,Medicine / Pulmnonology, Jinnah Medical and Dental College, Karachi, PAK
| | - Muhammad Ammar
- Internal Medicine, Dow International Medical College, Karachi, PAK.,Section of Pulmonary and Critical Care Medicine, Aga Khan University, Karachi, PAK
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Syed H, Ascoli C, Linssen CF, Vagts C, Iden T, Syed A, Kron J, Polly K, Perkins D, Finn PW, Novak R, Drent M, Baughman R, Sweiss NJ. Infection prevention in sarcoidosis: proposal for vaccination and prophylactic therapy. SARCOIDOSIS VASCULITIS AND DIFFUSE LUNG DISEASES 2020; 37:87-98. [PMID: 33093774 PMCID: PMC7569559 DOI: 10.36141/svdld.v37i2.9599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
Abstract
Sarcoidosis is a systemic inflammatory disease characterized by granuloma formation in affected organs and caused by dysregulated immune response to an unknown antigen. Sarcoidosis patients receiving immunosuppressive medications are at increased risk of infection. Lymphopenia is also commonly seen among patient with sarcoidosis. In this review, risk of infections, including opportunistic infections, will be outlined. Recommendations for vaccinations and prophylactic therapy based on literature review will also be summarized. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (2): 87-98).
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Affiliation(s)
- Huzaefah Syed
- Division of Rheumatology, Allergy, and Immunology, Virginia Commonwealth University, Richmond, VA, USA
| | - Christian Ascoli
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Catharina Fm Linssen
- Department of Medical Microbiology, Zuyderland Medical Centre, Heerlen/Sittard-Geleen, the Netherlands
| | - Christen Vagts
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Thomas Iden
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Aamer Syed
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - Jordana Kron
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Kelly Polly
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA, USA
| | - David Perkins
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
| | - Patricia W Finn
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA
| | - Richard Novak
- Division of Infectious Diseases, University of Illinois at Chicago, Chicago, IL, USA
| | - Marjolein Drent
- ILD Center of Excellence, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Pharmacology and Toxicology, FHML, Maastricht University, Maastricht, The Netherlands
| | - Robert Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Nadera J Sweiss
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois at Chicago, Chicago, IL, USA.,Division of Rheumatology, University of Illinois at Chicago, Chicago, IL, USA
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118
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Gold JAW, Jackson BR, Benedict K. Possible Diagnostic Delays and Missed Prevention Opportunities in Pneumocystis Pneumonia Patients Without HIV: Analysis of Commercial Insurance Claims Data-United States, 2011-2015. Open Forum Infect Dis 2020; 7:ofaa255. [PMID: 32704515 DOI: 10.1093/ofid/ofaa255] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 06/19/2020] [Indexed: 11/13/2022] Open
Abstract
Background Pneumocystis pneumonia (PCP) is a life-threatening but treatable and preventable fungal infection in immunocompromised persons. Previous studies suggest that persons without HIV who develop PCP (PCPHIV-) experience more acute, severe illness than persons with HIV who develop PCP (PCPHIV+). We analyzed health insurance claims data to compare demographics, underlying conditions, symptoms, and prescriptions for PCPHIV+ and PCPHIV-. Methods We used the IBM MarketScan Research Databases to identify patients diagnosed with PCP during 2011-2015. We analyzed claims 1 year before to 3 months after diagnosis to compare PCPHIV+ and PCPHIV-. Results Among 3938 patients, 70.4% were PCPHIV-. Compared with PCPHIV+, PCPHIV- were more likely to be older (median, 60 vs 45 years; P < .0001), female (51.5% vs 20.2%; P < .0001), hypoxemic (13.5% vs 7.1%; P < .0001), and to die within 90 days (6.6% vs 4.2%; P < .0001). The most common underlying conditions among PCPHIV- included chronic pulmonary diseases (54.6%), solid tumors (35.1%), hematologic malignancies (20.1%), and rheumatologic conditions (14.0%). The median time between the first visit for PCP-related symptoms and PCP diagnosis was longer for PCPHIV- than PCPHIV+ (25 vs 16 days; P < .0001). In the 3 months before PCP diagnosis, PCPHIV- were less likely to have an outpatient prescription for PCP prophylaxis than PCPHIV+ (6.9% vs 10.6%; P = .0001). Conclusions PCPHIV- may experience a prolonged illness course and diagnostic delays compared with PCPHIV+. Clinicians should maintain a high index of suspicion for PCP in immunocompromised patients with compatible symptoms, regardless of HIV status.
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Affiliation(s)
- Jeremy A W Gold
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Kaitlin Benedict
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Gupta S, Hinkamp CA, Lo M. Urine antigen-negative disseminated histoplasmosis mimicking post-transplant lymphoproliferative disorder. BMJ Case Rep 2020; 13:13/6/e233976. [PMID: 32532906 DOI: 10.1136/bcr-2019-233976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A 50-year-old woman with a history of kidney transplant presented with 2 days of abdominal pain after 6 months of recurrent streptococcal pharyngitis, fevers, weight loss and a new rash on her chest and back. Her examination was notable for a unilateral tonsillar exudate and 2-3 mm pink papules with a fine scale over her chest and back. CT of the abdomen and chest demonstrated several large lymph nodes, and laboratory investigation revealed new cytopenias and elevated transaminases. Urine antigen testing for Histoplasma capsulatum was negative, but a fungal complement fixation panel was reactive for Histoplasma antibodies. Skin biopsy revealed intracellular organisms consistent with H. capsulatum She underwent treatment with liposomal amphotericin B but due to nephrotoxicity, drug interactions and worsening transaminitis, therapy was changed to itraconazole. The diagnosis and management of disseminated histoplasmosis presents multiple challenges, which are of particular importance in patients with a history of renal transplantation.
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Affiliation(s)
- Surbhi Gupta
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Colin Andrew Hinkamp
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew Lo
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Ghembaza A, Vautier M, Cacoub P, Pourcher V, Saadoun D. Risk Factors and Prevention of Pneumocystis jirovecii Pneumonia in Patients With Autoimmune and Inflammatory Diseases. Chest 2020; 158:2323-2332. [PMID: 32502592 DOI: 10.1016/j.chest.2020.05.558] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/21/2020] [Accepted: 05/28/2020] [Indexed: 02/02/2023] Open
Abstract
Patients with autoimmune and/or inflammatory diseases (AIIDs) are prone to serious infectious complications such as Pneumocystis jirovecii pneumonia (PJP). In non-HIV patients, the prognosis is poorer, and diagnostic tests are of lower sensitivity. Given the low incidence of PJP in AIIDs, with the exception of granulomatosis with polyangiitis, and the non-negligible side effects of chemoprophylaxis, routine prescription of primary prophylaxis is still debated. Absolute peripheral lymphopenia, high doses of corticosteroids, combination with other immunosuppressive agents, and concomitant lung disease are strong predictors for the development of PJP and thus should warrant primary prophylaxis. Trimethoprim-sulfamethoxazole is considered first-line therapy and is the most extensively used drug for PJP prophylaxis. Nevertheless, it may expose patients to side effects. Effective alternative drugs such as atovaquone or aerosolized pentamidine could be used when trimethoprim-sulfamethoxazole is not tolerated or contraindicated. No standard guidelines are available to guide PJP prophylaxis in patients with AIIDs. This review covers the epidemiology, risk factors, and prevention of pneumocystis in the context of AIIDs.
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Affiliation(s)
- Amine Ghembaza
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Mathieu Vautier
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Patrice Cacoub
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France
| | - Valérie Pourcher
- Service des maladies infectieuses et tropicales, hôpital Pitié-Salpêtrière, AP-HP, Paris, France; INSERM UMR-S 1136, Pierre Louis Institute of Epidemiology and Public Health, Sorbonne Université, Paris, France
| | - David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Centre national de références Maladies Autoimmunes systémiques rares et Centre national de références Maladies Autoinflammatoires et amylose inflammatoire; Immunology-Immunopathology-Immunotherapy (I3), Sorbonne Universités, UPMC Université Paris 6, INSERM, UMR S 959, Paris, France.
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Okazaki A, Shiba Y, Shibata K, Kasahara K. Multiple fungus balls in rheumatoid arthritis–associated honeycomb lung. Clin Rheumatol 2020; 39:2017-2018. [DOI: 10.1007/s10067-020-05096-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/28/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
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Bavaro DF, Fiordelisi D, Angarano G, Monno L, Saracino A. Targeted therapies for autoimmune/idiopathic nonmalignant diseases: risk and management of opportunistic infections. Expert Opin Drug Saf 2020; 19:817-842. [PMID: 32394759 DOI: 10.1080/14740338.2020.1767585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The management of patients affected by autoimmune/idiopathic diseases has been revolutionized by the development of targeted therapies (TT). However, the use of TT is complicated by several adverse events, like opportunistic infections (OIs). The potential of TT to predispose to OIs mainly depends on the site of action; nevertheless, such associations are far from being deterministic, because many factors could increase the infection risk. AREAS COVERED The impact on the infective risk of different TT used for autoimmune/idiopathic diseases is far from being completely understood. Indeed, many post-marketing reports documented severe or unexpected infections in patients treated with TT that did not emerge during registrative trials. In this review, the authors attempt to provide an easy and practical update about the 'infectious' safety of TT and examine the management strategies of OIs and other infections more frequently observed in the course of treatment with TT. EXPERT OPINION The authors suggest to precisely schedule the clinical management of these subjects, both to prevent and eventually treat promptly the TT-related infectious complications. A coordinated approach should be implemented from different medical specialties to improve the overall understanding of safety of TT and, in general, the management of opportunistic infections in immune-compromised hosts.
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Affiliation(s)
- Davide Fiore Bavaro
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Deborah Fiordelisi
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Gioacchino Angarano
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Laura Monno
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
| | - Annalisa Saracino
- Department of Biomedical Sciences and Human Oncology, Clinic of Infectious Diseases, University of Bari "Aldo Moro" , Bari, Italy
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Manglani R, Pavosevic HT, Han L, Epelbaum O. Close encounters of three kinds: Case-based report of endemic mycoses in the environs of New York city. Respir Med Case Rep 2020; 30:101106. [PMID: 32551220 PMCID: PMC7289762 DOI: 10.1016/j.rmcr.2020.101106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/26/2020] [Indexed: 11/01/2022] Open
Abstract
The term "endemic mycoses" refers to a group of fungi that maintains a baseline rate of infection only in certain geographical regions due to the hospitable enviormental conditions these regions offer. In the United States, Histoplasma capsulatum, Coccidioides spp, and Blastomyces dermatitidis are the three most prevalent endemic human fungal infections. The traditional endemic regions for these pathogens are defined based on data acquired many decades ago, and case detection is subject to diagnostic delays even in classically endemic areas, a problem that is likely to be magnified in areas less familiar with these fungal infections. The present series includes an example of each of these infections diagnosed in a medical center situated in the suburbs of New York City, a location not considered endemic for any of them. Likely routes of acquisition for the three patients are considered, and the history of encounters with these pathogens in New York State is briefly recounted. Altogether, this report is intended to serve as a reminder to clinicians that traditional distribution maps for the endemic mycoses are bound to be outdated in the face of modern trends in globalization, population dynamics, and ecological change.
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Affiliation(s)
- Ravi Manglani
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
| | | | - Liying Han
- Department of Pathology, Westchester Medical Center, Valhalla, NY, USA
| | - Oleg Epelbaum
- Division of Pulmonary, Critical Care and Sleep Medicine, Westchester Medical Center, Valhalla, NY, USA
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Wu HH, Chen YX, Fang SY. Pleural effusion in an immunocompetent host with cryptococcal pneumonia: A case report. World J Clin Cases 2020; 8:1295-1300. [PMID: 32337205 PMCID: PMC7176623 DOI: 10.12998/wjcc.v8.i7.1295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/06/2020] [Accepted: 03/26/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pulmonary cryptococcosis is an opportunistic infection that mainly occurs among immunocompromised patients although it can sometimes occur in immunocompetent individuals. However, the imaging findings of pulmonary cryptococcosis in immunocompetent hosts differ from those in immunosuppressed patients. In addition, the most common imaging findings of isolated pulmonary cryptococcosis are single or multiple nodules. Cavities and the halo sign are, however, prevalent in immunosuppressed patients. In immunocompetent patients, lung consolidation, pleural effusion or cavities are scarce.
CASE SUMMARY A 29-year-old Asian male was admitted to our hospital with complaints of cough and fever that had persisted for a month. As a chest computed tomography scan showed consolidation in his left lower lobe, he was initially diagnosed with pneumonia and received antibiotic treatment. A second review of the chest computed tomography image revealed multiple cavities and pleural effusion. Flexible fiberoptic bronchoscopy was subsequently performed, bronchoalveolar lavage fluid and serum cryptococcal antigen tests were positive. Cryptococcus capsules were observed in bronchoalveolar lavage fluid ink stain. Histopathological examination of a percutaneous lung biopsy from the left lower lobe further revealed granulomatous inflammation, and periodic acid-Schiff staining showed red-colored yeast walls, signifying pulmonary cryptococcosis. The patient was then treated with a daily dose of fluconazole (0.4 g), but the cough and fever still persisted. We therefore changed treatment to voriconazole (0.2 g, twice a day), and the patient’s clinical outcome was satisfactory.
CONCLUSION Although rare, clinicians should not disregard the possibility of cavities and pleural effusion occurring in immunocompetent hosts without underlying diseases.
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Affiliation(s)
- Huan-Huan Wu
- Department of Respiratory Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang 322100, Zhejiang Province, China
| | - Yan-Xiao Chen
- Department of Evidence-base Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang 322100, Zhejiang Province, China
| | - Shuang-Yan Fang
- Department of Respiratory Medicine, Dongyang Hospital Affiliated to Wenzhou Medical University, Dongyang 322100, Zhejiang Province, China
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Odashima K, Kagiyama N, Kanauchi T, Ishiguro T, Takayanagi N. Incidence and etiology of chronic pulmonary infections in patients with idiopathic pulmonary fibrosis. PLoS One 2020; 15:e0230746. [PMID: 32243456 PMCID: PMC7122739 DOI: 10.1371/journal.pone.0230746] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 03/07/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The incidence and etiologies of chronic pulmonary infection (CPI) in patients with idiopathic pulmonary fibrosis (IPF) have been poorly investigated. METHODS We conducted a retrospective study of 659 patients with IPF to assess the incidence, etiologies, and risk factors of CPI development. CPI was defined if the etiology of infection was diagnosed one or more months after the onset of symptoms or upon the appearance of new shadows on pulmonary radiological images. RESULTS At IPF diagnosis, 36 (5.5%) patients had CPI, and 46 (7.0%) patients without CPI at IPF diagnosis developed CPI over a median follow-up period of 6.1 years. The incidence density of CPI development was 18.90 cases per 1000 person-years. Detected organisms from these 46 patients were Mycobacterium avium complex in 20 patients, other nontuberculous mycobacteria in 4, M. tuberculosis in 7, Aspergillus spp. in 22, and Nocardia sp. in one. In a multivariate Cox regression hazard model, PaO2 <70 Torr and KL-6 ≥2000 U/mL were associated with CPI development. CONCLUSIONS Nontuberculous mycobacteria, M. tuberculosis, and Aspergillus and Nocardia spp. were the four most frequent etiologies of CPI in patients with IPF. During follow-up of IPF, clinicians should pay attention to the development of CPI, especially in patients with PaO2 <70 Torr or KL-6 ≥2000 U/mL.
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Affiliation(s)
- Kyuto Odashima
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
- * E-mail:
| | - Naho Kagiyama
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
| | - Tetsu Kanauchi
- Department of Radiology, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
| | - Takashi Ishiguro
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
| | - Noboru Takayanagi
- Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center, Saitama, Japan
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Abstract
Anti-neutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) is a small to medium vessel vasculitis associated with excess morbidity and mortality. This review explores how management of AAV has evolved over the past two decades with pivotal randomized controlled trials shaping the management of induction and maintenance of remission. Contemporary AAV care is characterized by approaches that minimize the cumulative exposure to cyclophosphamide and glucocorticoids, increasingly use rituximab for remission induction and maintenance, and consider therapies with less toxicity (for example, methotrexate, mycophenolate mofetil) for manifestations of AAV that do not threaten organ function or survival. Simultaneously, improvements in outcomes, such as renal and overall survival, have been observed. Additional trials and observational studies evaluating the comparative effectiveness of agents for AAV in various patient subgroups are needed. Prospective studies are necessary to assess the effect of psychosocial interventions on patient reported outcomes in AAV. Despite the expanding array of treatments for AAV, little guidance on how to personalize AAV care is available to physicians.
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Affiliation(s)
- Zachary S Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Mongan Institute, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eli M Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Tasaka S. Recent Advances in the Diagnosis and Management of Pneumocystis Pneumonia. Tuberc Respir Dis (Seoul) 2020; 83:132-140. [PMID: 32185915 PMCID: PMC7105429 DOI: 10.4046/trd.2020.0015] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
In human immunodeficiency virus (HIV)-infected patients, Pneumocystis jirovecii pneumonia (PCP) is a wellk-nown opportunistic infection and its management has been established. However, PCP is an emerging threat to immunocompromised patients without HIV infection, such as those receiving novel immunosuppressive therapeutics for malignancy, organ transplantation, or connective tissue diseases. Clinical manifestations of PCP are quite different between patients with and without HIV infections. In patients without HIV infection, PCP rapidly progresses, is difficult to diagnose correctly, and causes severe respiratory failure with a poor prognosis. High-resolution computed tomography findings are different between PCP patients with HIV infection and those without. These differences in clinical and radiological features are due to severe or dysregulated inflammatory responses that are evoked by a relatively small number of Pneumocystis organisms in patients without HIV infection. In recent years, the usefulness of polymerase chain reaction and serum β-D-glucan assay for rapid and non-invasive diagnosis of PCP has been revealed. Although corticosteroid adjunctive to anti-Pneumocystis agents has been shown to be beneficial in some populations, the optimal dose and duration remain to be determined. Recent investigations revealed that Pneumocystis colonization is prevalent and that asymptomatic carriers are at risk for developing PCP and can serve as the reservoir for the spread of Pneumocystis by airborne transmission. These findings suggest the need for chemoprophylaxis in immunocompromised patients as well as infection control measures, although the indications remain controversial. Because a variety of novel immunosuppressive therapeutics have been emerging in medical practice, further innovations in the diagnosis and treatment of PCP are needed.
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Affiliation(s)
- Sadatomo Tasaka
- Department of Respiratory Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.
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Mei H, Hu X, Wang J, Wang R, Cai Y. Determination of voriconazole in human plasma by liquid chromatography-tandem mass spectrometry and its application in therapeutic drug monitoring in Chinese patients. J Int Med Res 2020; 48:300060519887019. [PMID: 31771376 PMCID: PMC7607762 DOI: 10.1177/0300060519887019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/16/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To develop a liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of voriconazole in human plasma, and to evaluate its application in clinical therapeutic drug monitoring. METHOD Plasma samples were obtained from Chinese patients receiving voriconazole, precipitated with methanol (using fluconazole as an internal standard), and then subjected to LC-MS/MS using an SB C18 column with a methanol and water mobile phase at a flow rate of 0.4 mL/minute. Quantification was performed by multiple-reaction monitoring using the precursor and product ion pair m/z 350-280.9 for voriconazole and m/z 307-219.9 for fluconazole. RESULTS The calibration curve was linear over a range of 0.1-10.0 µg/mL (R2 = 0.9995). The inter-day and intra-day relative standard deviations were <7.68% and <8.97%, respectively. Extraction recovery, matrix effect, and stability were also validated. Sixty-eight plasma samples from 42 patients were analyzed, and the voriconazole concentrations in 25 samples (36.8%) were outside the optimal range of 1.5-4.5 µg/mL. CONCLUSIONS We developed a simple and accurate method of drug monitoring, which could improve the efficacy and prevent adverse reactions of voriconazole.
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Affiliation(s)
- Hekun Mei
- Center of Medicine Clinical Research, Department of Pharmacy, PLA General Hospital, Beijing, China
| | - Xing Hu
- Medical School of Chinese PLA, Beijing, China
| | - Jin Wang
- Center of Medicine Clinical Research, Department of Pharmacy, PLA General Hospital, Beijing, China
| | - Rui Wang
- Center of Medicine Clinical Research, Department of Pharmacy, PLA General Hospital, Beijing, China
| | - Yun Cai
- Center of Medicine Clinical Research, Department of Pharmacy, PLA General Hospital, Beijing, China
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Aberegg SK, Maddock SD, Blagev DP, Callahan SJ. Diagnosis of EVALI: General Approach and the Role of Bronchoscopy. Chest 2020; 158:820-827. [PMID: 32092322 DOI: 10.1016/j.chest.2020.02.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 01/08/2023] Open
Abstract
A 23-year-old man arrives at the ED with a 3-week history of dyspnea, dry cough, fevers, and night sweats. Two weeks previously, he was evaluated in an outpatient clinic and given a course of azithromycin for presumed infectious pneumonia. His symptoms did not improve, and he was seen 1 week later in an urgent care center and given a prescription for doxycycline, which he has been taking without improvement. He states that he feels miserable, has severe nausea and vomiting, and has not eaten in several days. His only medical history is childhood asthma. He reports no surgeries and takes no medications. He has no risk factors for HIV, does not smoke combustible cigarettes or use IV drugs, and has not recently traveled. Examination shows a room air saturation of 89%, a temperature of 38.3°C, and a respiratory rate of 22 breaths/min. Results of his examination are normal, and there are no rales or wheezing heard in the lungs. Chest radiograph shows bilateral, consolidative opacities. WBC count is 14,000, with left shift. Results of biochemistries are normal. Erythrocyte sedimentation rate is 104, and procalcitonin is 0.08. Urine toxicology screen is positive for tetrahydrocannabinol (THC). Asked specifically about vaping and e-cigarette use, he reports that he recently began using THC "carts" that his friend gets from an unknown supplier. What is the diagnosis and what additional steps are necessary to confirm it? Is bronchoscopy indicated?
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Affiliation(s)
| | | | - Denitza P Blagev
- University of Utah Health, Salt Lake City, UT; Intermountain Healthcare, Murray, UT
| | - Sean J Callahan
- University of Utah Health, Salt Lake City, UT; George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT.
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Mecoli CA, Danoff SK. Pneumocystis jirovecii Pneumonia and Other Infections in Idiopathic Inflammatory Myositis. Curr Rheumatol Rep 2020; 22:7. [PMID: 32020305 PMCID: PMC7223401 DOI: 10.1007/s11926-020-0883-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose of Review The management of patients with idiopathic inflammatory myositis (IIM) can be complex and challenging due to the myriad of complications they can experience. The continued use of corticosteroids, in addition to the rise of combination immunosuppressive therapy, has contributed to the ongoing concern for infection. Perhaps the most feared infection in IIM patients is Pneumocystis jirovecii pneumonia (PJP) given its infrequent occurrence yet high mortality. The field has been, and continues to be, without evidence-based guidelines to help clinicians determine which patients with IIM to prescribe prophylaxis. Herein, we review this literature to provide the clinician with an up-to-date view of infections in IIM. Recent Findings In the past 5 years, a number of studies have been reported highlighting various infectious complications, which help us better understand their frequency and associated risk factors. In addition, data has been published on the potential harms of PJP prophylaxis, to better inform the risk/benefit of our decision-making. Summary Infection remains a major contributor to morbidity and mortality in IIM. A better understanding of which patient subgroups are at risk for particular infections will inform optimal management strategies.
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Affiliation(s)
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, MD, USA.
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131
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Effect of Gender and Age on Voriconazole Trough Concentrations in Italian Adult Patients. Eur J Drug Metab Pharmacokinet 2020; 45:405-412. [DOI: 10.1007/s13318-019-00603-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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132
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Chung MW, Kim UJ, Jun CH, Cho SB, Park SY, Park CH, Kim HS, Choi SK, Rew JS. Pneumocystis pneumonia after use of corticosteroids in a man with severe alcoholic hepatitis: A case report. Medicine (Baltimore) 2020; 99:e18696. [PMID: 31914071 PMCID: PMC6959895 DOI: 10.1097/md.0000000000018696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Severe alcoholic hepatitis (AH) has a very high mortality rate. Current guidelines recommend oral corticosteroids as first-line agents in individuals with severe AH to reduce short-term mortality. However, systemic corticosteroids have serious adverse effects. In individuals with AH, infection, which is one of the complications of steroid use, can result in serious outcomes, such as acute-on-chronic liver failure. Pneumocystis pneumonia (PCP) is a life-threatening opportunistic infection which may occur when high-dose corticosteroids are prescribed for more than 1 month. Therefore, when high-dose corticosteroids are used, providing PCP prophylaxis is warranted. Although trimethoprim-sulfamethoxazole (TMP-SMX) is the drug of choice for the prophylaxis of PCP, its hepatotoxicity limits its use in patients with severe AH who are on high-dose corticosteroids. Moreover, there is a lack of consensus on which drugs should be used for PCP prophylaxis in individuals with severe AH who are on glucocorticoid treatment. Herein, we report a case of a 43-year-old male with fatal PCP that occurred after the use of corticosteroids for severe AH. PATIENT CONCERNS A 43-year-old alcoholic man presented with a hematoma on his right leg. His liver function was poor, and he was he was diagnosed with severe AH and treated with oral corticosteroids for 26 days. After glucocorticoid treatment, he developed a productive cough. DIAGNOSES A sputum PCR test was positive for Pneumocystis jirovecii. INTERVENTIONS He was initially treated with TMP-SMX and required artificial ventilation. OUTCOMES He developed disseminated intravascular coagulation and multi-organ failure, and died 10 days after starting TMP-SMX. LESSONS To date, prevention of PCP in individuals with severe AH who are on corticosteroids has been overlooked. This case illustrates the need for prophylaxis of PCP in individuals with severe AH taking corticosteroids.
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Affiliation(s)
| | - Uh Jin Kim
- Department of Infectious diseases, Chonnam National University Hospital and College of Medicine, Gwangju, South Korea
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Chen PY, Yu CJ, Chien JY, Hsueh PR. Anidulafungin as an alternative treatment for Pneumocystis jirovecii pneumonia in patients who cannot tolerate trimethoprim/sulfamethoxazole. Int J Antimicrob Agents 2020; 55:105820. [PMID: 31622654 DOI: 10.1016/j.ijantimicag.2019.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/30/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
Evidence supporting the use of an echinocandin alone as an alternative agent for the treatment of Pneumocystis jirovecii pneumonia (PCP) is limited and controversial. This retrospective cohort study was conducted at National Taiwan University Hospital from 1 July 2015 to 31 December 2017. Using multivariable Cox regression analyses, the outcomes of patients receiving trimethoprim/sulfamethoxazole (TMP-SMZ) or anidulafungin single therapy as an alternative treatment for PCP were investigated. A total of 207 patients with PCP were screened and 170 patients were included in the final analysis, among whom 134 (78.8%) received TMP-SMZ and 36 (21.2%) received anidulafungin as alternative anti-PCP treatment. Overall 60-day mortality was 34.1% (58/170), and 60-day mortality did not differ significantly between the anidulafungin group (38.9%; 14/36) and the TMP-SMZ group (32.8%; 44/134) (P = 0.554). Age ≥60 years [hazard ratio (HR) = 1.840, 95% confidence interval (CI) 1.039-3.259; P = 0.036] and HIV infection (HR = 0.102, 95% CI 0.013-0.771; P = 0.027) independently predicted 60-day mortality. Patients with lower SpO2/FiO2 ratio (HR = 0.994, 95% CI 0.990-0.998; P = 0.005) showed a higher 60-day mortality. In the Kaplan-Meier survival analysis, anidulafungin as alternative anti-PCP treatment was not correlated with higher mortality (P = 0.605). Using TMP-SMZ or anidulafungin as alternative anti-PCP treatment had similar 60-day mortality. These findings suggest that anidulafungin therapy may be an effective and alternative treatment for PCP in patients who cannot tolerate TMP-SMZ.
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Affiliation(s)
- Po-Yi Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan
| | - Jung-Yien Chien
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan.
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, No. 7 Chung-Shan S. Road, Taipei 100, Taiwan.
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134
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Li V, Jasinarachchi M, Butler E. Epidemiology, symptomatology and treatment of patients with myasthenia gravis in an Australian hospital. Intern Med J 2019; 49:1537-1540. [DOI: 10.1111/imj.14662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Vivien Li
- Department of NeurologyFrankston Hospital, Peninsula Health Melbourne Victoria Australia
| | - Mahi Jasinarachchi
- Department of NeurologyFrankston Hospital, Peninsula Health Melbourne Victoria Australia
| | - Ernest Butler
- Department of NeurologyFrankston Hospital, Peninsula Health Melbourne Victoria Australia
- National Hospital for Neurology and Neurosurgery London United Kingdom
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135
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Gaborit BJ, Tessoulin B, Lavergne RA, Morio F, Sagan C, Canet E, Lecomte R, Leturnier P, Deschanvres C, Khatchatourian L, Asseray N, Garret C, Vourch M, Marest D, Raffi F, Boutoille D, Reignier J. Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study. Ann Intensive Care 2019; 9:131. [PMID: 31776705 PMCID: PMC6881486 DOI: 10.1186/s13613-019-0604-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/13/2019] [Indexed: 01/11/2023] Open
Abstract
Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p < 0.05), a P. jirovecii microscopy-positive result from bronchoalveolar lavage (BAL) (OR, 1.3; 95% CI 1.54–9.3; p < 0.05); and absence of a BAL fluid alveolitis profile (OR, 3.2; 95% CI 1.27–8.8; p < 0.04). The 90-day mortality rate was 27%, increasing to 50% in the severe PJP group. Factors independently associated with 90-day mortality were worse SOFA score on day 1 (OR, 1.05; 95% CI 1.02–1.09; p < 0.001) whereas alveolitis at BAL was protective (OR, 0.79; 95% CI 0.65–0.96; p < 0.05). In the subgroup of HIV-negative patients, similar findings were obtained, then viral co-infection were independently associated with higher 90-day mortality (OR, 1.25; 95% CI 1.02–1.55; p < 0.05). Conclusions Older age and P. jirovecii oocysts at microscopic examination of BAL were independently associated with severe PJP. Both initial PJP severity as evaluated by the SOFA score and viral co-infection predicted 90-day mortality. Alveolitis at BAL examination was associated with less severe PJP. The pathophysiological mechanism underlying this observation deserves further investigation.
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Affiliation(s)
- Benjamin Jean Gaborit
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France. .,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France.
| | - Benoit Tessoulin
- Service d'Hématologie, University Hospital, INSERM, U1232, Université de Nantes, Nantes, France
| | - Rose-Anne Lavergne
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | - Florent Morio
- Laboratoire de Parasitologie-Mycologie, Institut de Biologie, University Hospital, Nantes, France
| | | | - Emmanuel Canet
- Medical Intensive Care, University Hospital, Nantes, France
| | - Raphael Lecomte
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Paul Leturnier
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Colin Deschanvres
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Lydie Khatchatourian
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - Nathalie Asseray
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | | | - Michael Vourch
- Medical Intensive Care, University Hospital, Nantes, France
| | | | - François Raffi
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France
| | - David Boutoille
- Department of Infectious Diseases, Hôtel-Dieu University Hospital, University Hospital of Nantes and CIC 1413, INSERM, 1 Place Alexis-Ricordeau, 44000, Nantes, France.,EA 3826, Laboratory of Clinical and Experimental Therapeutics of Infections, IRS2-Nantes Biotech, Nantes, France
| | - Jean Reignier
- Medical Intensive Care, University Hospital, Nantes, France
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136
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Comparison of Clinical Manifestation, Diagnosis, and Outcomes of Invasive Pulmonary Aspergillosis and Pulmonary Mucormycosis. Microorganisms 2019; 7:microorganisms7110531. [PMID: 31694308 PMCID: PMC6920790 DOI: 10.3390/microorganisms7110531] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/31/2019] [Accepted: 11/03/2019] [Indexed: 12/30/2022] Open
Abstract
Objects: Invasive pulmonary mold infection usually has devastating outcomes. Timely differentiation between invasive pulmonary aspergillosis (IPA) from pulmonary mucormycosis (PM) is critical for treatment decision-making. However, information on IPA and PM differentiation is limited. Methods: We conducted a retrospective, multicenter, observational study, with proven and probable IPA and PM patients from January 2004 to December 2017. Demographics, clinical manifestations, image reports, histopathological findings, and outcomes were analyzed. Results: A total of 46 IPA (33 proven and 13 probable) and 19 PM (18 proven and one probable) cases were analyzed. The majority of tissues (81% in IPA and 61% in PM) were obtained using bronchoscopy. Prior influenza infection was a predisposing factor for IPA, and abscess formation in CT scan was associated with PM (p = 0.0491, p = 0.0454, respectively). The positive culture rate for PM was lower than that for IPA (37% vs. 67%, p = 0.0294). The galactomannan (GM) level from serum and bronchoalveolar lavage (BAL) fluid was significantly higher in IPA than in PM (3.3 ± 0.5 vs. 0.8 ± 0.6, p = 0.0361; 4.0 ± 0.6 vs. 0.59 ± 0.1, p = 0.0473, respectively). The overall mortality rate was 65%, which was similar among IPA and PM groups. Systemic steroid exposure and high Acute Physiology and Chronic Health Evaluation II (APACHE II) scores on admission were independently correlated to mortality in IPA (p = 0.027, p = 0.026, respectively). However, there was no predictor for mortality found in PM patients. Conclusions: Influenza infection, abscess formation in CT scan, and GM level may help physicians to differentiate IPA and PM. Bronchoscopy-guided biopsy and lavage specimen provide timely and definite diagnosis. The prognosis of IPA is associated with systemic steroid exposure and higher APACHE II scores on admission.
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137
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Liu Y, Zhang Y, Zhao W, Liu X, Hu F, Dong B. Pharmacotherapy of Lower Respiratory Tract Infections in Elderly-Focused on Antibiotics. Front Pharmacol 2019; 10:1237. [PMID: 31736751 PMCID: PMC6836807 DOI: 10.3389/fphar.2019.01237] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 09/27/2019] [Indexed: 02/05/2023] Open
Abstract
Lower respiratory tract infections (LRTIs) refer to the inflammation of the trachea, bronchi, bronchioles, and lung tissue. Old people have an increased risk of developing LRTIs compared to young adults. The prevalence of LRTIs in the elderly population is not only related to underlying diseases and aging itself, but also to a variety of clinical issues, such as history of hospitalization, previous antibacterial therapy, mechanical ventilation, antibiotic resistance. These factors mentioned above have led to an increase in the prevalence and mortality of LRTIs in the elderly, and new medical strategies targeting LRTIs in this population are urgently needed. After a systematic review of the current randomized controlled trials and related studies, we recommend novel pharmacotherapies that demonstrate advantages for the management of LRTIs in people over the age of 65. We also briefly reviewed current medications for respiratory communicable diseases in the elderly. Various sources of information were used to ensure all relevant studies were included. We searched Pubmed, MEDLINE (OvidSP), EMBASE (OvidSP), and ClinicalTrials.gov. Strengths and limitations of these drugs were evaluated based on whether they have novelty of mechanism, favorable pharmacokinetic/pharmacodynamic profiles, avoidance of interactions and intolerance, simplicity of dosing, and their ability to cope with challenges which was mainly evaluated by the primary and secondary endpoints. The purpose of this review is to recommend the most promising antibiotics for treatment of LRTIs in the elderly (both in hospital and in the outpatient setting) based on the existing results of clinical studies with the novel antibiotics, and to briefly review current medications for respiratory communicable diseases in the elderly, aiming to a better management of LRTIs in clinical practice.
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Affiliation(s)
- Yang Liu
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
| | - Yan Zhang
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
| | - Wanyu Zhao
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
| | - Xiaolei Liu
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
| | - Fengjuan Hu
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
| | - Birong Dong
- The Center of Gerontology and Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Geriatric Health Care and Medical Research Center, Sichuan University, Chengdu, China
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138
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Wang Y, McGuire TM, Hollingworth SA, Dong Y, Van Driel ML. Antifungal agents for invasive candidiasis in non-neutropenic critically ill adults: What do the guidelines recommend? Int J Infect Dis 2019; 89:137-145. [PMID: 31639522 DOI: 10.1016/j.ijid.2019.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/07/2019] [Accepted: 10/13/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Recommendations in clinical practice guidelines (CPG) may differ and cause confusion. Our objective was to appraise CPGs for antifungal treatment of invasive candidiasis (IC) in non-neutropenic critically ill adult patients. METHODS We systematically searched the literature for CPGs published between 2008 and 2018. We assessed the quality of each guideline using six domains of the AGREE II instrument. We extracted and compared recommendations for different treatment strategies and assessed content quality. RESULTS Of 19 guidelines, the mean overall AGREE II score was 58%. The domain 'clarity of presentation' received the highest scores (88%) and 'applicability' the lowest (18%). CPGs provided detailed recommendations on antifungal prophylaxis (n = 10), with fluconazole recommended as initial prophylaxis in all seven CPGs citing a specific drug. Echinocandin was recommended as the initial drug in all 16 CPGs supporting empirical/pre-emptive treatment; and in 18 of 19 for targeted invasive candidiasis treatment. However, it remains unclear when to initiate prophylaxis, empirical or pre-emptive therapy or when to step down. CONCLUSIONS The methodological quality of CPGs for antifungal treatment of IC in non-neutropenic critically ill patients is suboptimal. Some treatment recommendations were inconsistent across indications and require local guidance to help clinicians make better informed decisions.
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Affiliation(s)
- Yan Wang
- Department of Pharmacy, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China; School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia.
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Woolloongabba, Queensland, Australia; Faculty of Health Sciences & Medicine, Bond University, Robina, Queensland, Australia; Mater Pharmacy, Mater Health, Brisbane, Queensland, Australia.
| | | | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China.
| | - Mieke L Van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Herston, Queensland, Australia.
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139
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Roux D, Gaudry S, Dreyfuss D. Conventional amphotericin B should remain in the armamentarium as a cheap and efficient waiting solution. Intensive Care Med 2019; 46:558-559. [PMID: 31620834 DOI: 10.1007/s00134-019-05782-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Damien Roux
- AP-HP, Hôpital Louis Mourier, Service de Médecine Intensive Réanimation, 178 rue Des Renouillers, 92700, Colombes, France.,Université de Paris, IAME, UMR 1137, 75018, Paris, France.,INSERM, IAME, UMR 1137, 75018, Paris, France
| | - Stéphane Gaudry
- AP-HP, Hôpital Avicenne, Service De Médecine Intensive Réanimation, 93000, Bobigny, France.,INSERM, UMR S1155, Sorbonne Université, 75020, Paris, France
| | - Didier Dreyfuss
- AP-HP, Hôpital Louis Mourier, Service de Médecine Intensive Réanimation, 178 rue Des Renouillers, 92700, Colombes, France. .,Université de Paris, IAME, UMR 1137, 75018, Paris, France. .,INSERM, UMR S1155, Sorbonne Université, 75020, Paris, France.
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140
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Jagannathan M. The Infectious Danger of Corticosteroids: A Fatal Case of Pneumocystis Jirovecii Pneumonia in a Non-HIV Patient Following Corticosteroid Use with Prophylaxis. Cureus 2019; 11:e5874. [PMID: 31763097 PMCID: PMC6834094 DOI: 10.7759/cureus.5874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Pneumocystis jirovecii pneumonia (PJP), historically regarded as an AIDS-defining illness, has been increasingly reported in non-HIV patients due to a myriad of risk factors resulting in immunosuppression. One of the more salient risk factors is corticosteroid use, including both low and high doses in prolonged, short-course, and intermittent-course regimens. The stance on PJP prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) for non-HIV patients on corticosteroids alone (e.g., for inflammatory conditions) is unclear, with no official guidelines classifying patients by dosage, length of treatment, or preexisting conditions. Additionally, clinicians often prescribe significant dosages of corticosteroids without proper consideration of the immunosuppressive risk. Here, we describe a case of a non-HIV patient with suspected dermatomyositis who was initially prescribed prednisone 15 mg daily with no prophylaxis for one month, then increased prednisone 80 mg daily with added TMP-SMX prophylaxis. Three days following increase, the patient developed significant PJP-associated pneumomediastinum and expired within one week despite mechanical ventilation and aggressive TMP-SMX treatment. This deterioration within days following corticosteroid increase with appropriately prescribed prophylaxis is an unusual presentation of PJP pneumonia and emphasizes the fulminant progression of the disease. The unnecessary over-prescription of steroids in unconfirmed autoimmune conditions has led to an unfortunate increase in devastating infections such as PJP. Clinicians should maintain high clinical suspicion concerning the development of PJP pneumonia in corticosteroid patients as well as consider prophylaxis even before a significant steroid dose increase is prescribed.
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Affiliation(s)
- Megha Jagannathan
- Internal medicine, Wayne State University School of Medicine, Detroit, USA
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141
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Abstract
PURPOSE OF REVIEW This article describes the clinical presentation, diagnostic approach (including the use of novel diagnostic platforms), and treatment of select infectious and noninfectious etiologies of chronic meningitis. RECENT FINDINGS Identification of the etiology of chronic meningitis remains challenging, with no cause identified in at least one-third of cases. Often, several serologic, CSF, and neuroimaging studies are indicated, although novel diagnostic platforms including metagenomic deep sequencing may hold promise for identifying organisms. Infectious etiologies are more common in those at risk for disseminated disease, specifically those who are immunocompromised because of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), transplantation, or immunosuppressant medications. An important step in identifying the etiology of chronic meningitis is assembling a multidisciplinary team of individuals, including those with specialized expertise in ophthalmology, dermatology, rheumatology, and infectious diseases, to provide guidance regarding diagnostic procedures. SUMMARY Chronic meningitis is defined as inflammation involving the meninges that lasts at least 4 weeks and is associated with a CSF pleocytosis. Chronic meningitis has numerous possible infectious and noninfectious etiologies, making it challenging to definitively diagnose patients. Therefore, a multifaceted approach that combines history, physical examination, neuroimaging, and laboratory analysis, including novel diagnostic platforms, is needed. This article focuses on key aspects of the evaluation of and approach to patients with chronic meningitis. Specific infectious etiologies and differential diagnoses of subacute and chronic meningitis, including noninfectious etiologies, are addressed.
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142
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Ko RE, Na SJ, Huh K, Suh GY, Jeon K. Association of time-to-treatment with outcomes of Pneumocystis pneumonia with respiratory failure in HIV-negative patients. Respir Res 2019; 20:213. [PMID: 31554510 PMCID: PMC6761721 DOI: 10.1186/s12931-019-1188-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 09/11/2019] [Indexed: 12/29/2022] Open
Abstract
Background The prevalence of pneumocystis pneumonia (PCP) and associated hypoxic respiratory failure is increasing in human immunodeficiency virus (HIV)-negative patients. However, no prior studies have evaluated the effect of early anti-PCP treatment on clinical outcomes in HIV-negative patient with severe PCP. Therefore, this study investigated the association between the time to anti-PCP treatment and the clinical outcomes in HIV-negative patients with PCP who presented with hypoxemic respiratory failure. Methods A retrospective observational study was performed involving 51 HIV-negative patients with PCP who presented in respiratory failure and were admitted to the intensive care unit between October 2005 and July 2018. A logistic regression model was used to adjust for potential confounding factors in the association between the time to anti-PCP treatment and in-hospital mortality. Results All patients were treated with appropriate anti-PCP treatment, primarily involving trimethoprim/sulfamethoxazole. The median time to anti-PCP treatment was 58.0 (28.0–97.8) hours. Thirty-one (60.8%) patients were treated empirically prior to confirmation of the microbiological diagnosis. However, the hospital mortality rates were not associated with increasing quartiles of time until anti-PCP treatment (P = 0.818, test for trend). In addition, hospital mortality of patients received early empiric treatment was not better than those of patients received definitive treatment after microbiologic diagnosis (48.4% vs. 40.0%, P = 0.765). In a multiple logistic regression model, the time to anti-PCP treatment was not associated with increased mortality. However, age (adjusted OR 1.07, 95% CI 1.01–1.14) and failure to initial treatment (adjusted OR 13.03, 95% CI 2.34–72.65) were independently associated with increased mortality. Conclusions There was no association between the time to anti-PCP treatment and treatment outcomes in HIV-negative patients with PCP who presented in hypoxemic respiratory failure.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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143
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Setianingrum F, Rautemaa-Richardson R, Denning DW. Pulmonary cryptococcosis: A review of pathobiology and clinical aspects. Med Mycol 2019; 57:133-150. [PMID: 30329097 DOI: 10.1093/mmy/myy086] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/05/2018] [Indexed: 01/13/2023] Open
Abstract
Pulmonary cryptococcosis is an important opportunistic invasive mycosis in immunocompromised patients, but it is also increasingly seen in immunocompetent patients. The main human pathogens are Cryptococcus neoformans and C. gattii, which have a worldwide distribution. In contrast to cryptococcal meningitis, pulmonary cryptococcosis is still underdiagnosed because of limitations in diagnostic tools. It can mimic lung cancer, pulmonary tuberculosis, bacterial pneumonia, and other pulmonary mycoses both clinically and radiologically. Pulmonary nodules are the most common radiological feature, but these are not specific to pulmonary cryptococcosis. The sensitivity of culture of respiratory samples for Cryptococcus is poor and a positive result may also reflect colonisation. Cryptococcal antigen (CrAg) with lateral flow device is a fast and sensitive test and widely used on serum and cerebrospinal fluid, but sera from patients with pulmonary cryptococcosis are rarely positive in the absence of disseminated disease. Detection of CrAg from respiratory specimens might assist the diagnosis of pulmonary cryptococcosis but there are very few data. Molecular detection techniques such as multiplex reverse transcription polymerase chain reaction (RT-PCR) could also provide better sensitivity but these still require validation for respiratory specimens. The first line of treatment for pulmonary cryptococcosis is fluconazole, or amphotericin B and flucytosine for those with central nervous system involvement. Pulmonary cryptococcosis worsens the prognosis of cryptococcal meningitis. In this review, we summarize the biological aspects of Cryptococcus and provide an update on the diagnosis and management of pulmonary cryptococcosis.
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Affiliation(s)
- Findra Setianingrum
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Parasitology Department, Universitas Indonesia, Jakarta, Indonesia
| | - Riina Rautemaa-Richardson
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Mycology Reference Centre Manchester, ECMM Centre of Excellence in Clinical and Laboratory Mycology and Clinical Studies, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
| | - David W Denning
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, UK
- Department of Infectious Diseases, Wythenshawe Hospital Manchester University NHS Foundation Trust, Manchester, UK
- National Aspergillosis Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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144
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Bixby AL, Goldsborough S, Iuppa A, LeBlanc A, Schultz HE, VandenBerg A. Successful use of carbamazepine in a patient with drug rash with eosinophilia and systemic symptoms. Ment Health Clin 2019; 9:331-335. [PMID: 31534877 PMCID: PMC6728115 DOI: 10.9740/mhc.2019.09.331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) is a serious adverse drug reaction with a high mortality rate. Discontinuation of the causative agent is the primary treatment. History of DRESS may put patients at higher risk of future episodes; however, cross-reactivity between various medications is not well established. An 18-year-old African American male with a history of bipolar I disorder with psychotic features was admitted for mania on his home dose of divalproex. After 1 week, olanzapine was added for refractory symptoms, but due to elevated creatinine phosphokinase (CPK), it was subsequently discontinued, and he was started on lorazepam and lithium. One week later, the patient was transferred to the intensive care unit with elevated CPK, fever, thrombocytopenia, elevated serum creatinine, hypotension, diarrhea, mild rigidity, bilateral inducible ankle clonus, and a rash. All medications were discontinued except for lorazepam. The skin pathology report was consistent with a drug eruption, and he was started on prednisone. Given continued symptoms of mania, carbamazepine was initiated. After clinical and laboratory improvement, the patient was discharged on hospital day 59 with instructions to continue carbamazepine and lorazepam. A MEDLINE search revealed no published case reports of the successful use of carbamazepine in a patient with a history of DRESS. Information regarding cross-reactivity between medications is limited primarily to aromatic antiepileptics. In our case report, carbamazepine was successfully used in a patient with a recent episode of DRESS during olanzapine, lithium, and valproate use.
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Affiliation(s)
- Alexandra L Bixby
- Psychiatry Clinical Pharmacist Specialist, Department of Pharmacy, Beaumont Health, Southfield, Michigan.,House Officer, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan.,Resident, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan.,Clinical Assistant Processor, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan.,Clinical Specialist, Psychiatry & Neurology, Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
| | - Sarah Goldsborough
- Psychiatry Clinical Pharmacist Specialist, Department of Pharmacy, Beaumont Health, Southfield, Michigan
| | - Aaron Iuppa
- House Officer, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan
| | - Andrew LeBlanc
- Resident, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan
| | - Heather E Schultz
- Clinical Assistant Processor, Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan
| | - Amy VandenBerg
- Clinical Specialist, Psychiatry & Neurology, Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan
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145
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Hage CA, Carmona EM, Epelbaum O, Evans SE, Gabe LM, Haydour Q, Knox KS, Kolls JK, Murad MH, Wengenack NL, Limper AH. Microbiological Laboratory Testing in the Diagnosis of Fungal Infections in Pulmonary and Critical Care Practice. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2019; 200:535-550. [PMID: 31469325 PMCID: PMC6727169 DOI: 10.1164/rccm.201906-1185st] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Fungal infections are of increasing incidence and importance in immunocompromised and immunocompetent patients. Timely diagnosis relies on appropriate use of laboratory testing in susceptible patients.Methods: The relevant literature related to diagnosis of invasive pulmonary aspergillosis, invasive candidiasis, and the common endemic mycoses was systematically reviewed. Meta-analysis was performed when appropriate. Recommendations were developed using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: This guideline includes specific recommendations on the use of galactomannan testing in serum and BAL and for the diagnosis of invasive pulmonary aspergillosis, the role of PCR in the diagnosis of invasive pulmonary aspergillosis, the role of β-d-glucan assays in the diagnosis of invasive candidiasis, and the application of serology and antigen testing in the diagnosis of the endemic mycoses.Conclusions: Rapid, accurate diagnosis of fungal infections relies on appropriate application of laboratory testing, including antigen testing, serological testing, and PCR-based assays.
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146
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Huang SH, Chuang YC, Lee YC, Hung CC, Sheng WH, Su JJ, Sun HY, Chen YC, Chang SC. Lumbar puncture for non-HIV-infected non-transplant patients with cryptococcosis: Should it be mandatory for all? PLoS One 2019; 14:e0221657. [PMID: 31437259 PMCID: PMC6705819 DOI: 10.1371/journal.pone.0221657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The indications for lumbar puncture in non-HIV-infected, non-transplant (NHNT) patients with cryptococcosis without meningeal signs need to be more fully defined. OBJECTIVES This study was designed to determine the optimal predictors of central nervous system (CNS) involvement in adult NHNT patients with cryptococcosis. METHODS The study population consisted of adult NHNT patients with culture-confirmed cryptococcosis who sought care at a university hospital in Taiwan from 2002 to 2016. We used a case-control method to identify the clinical characteristics and laboratory findings associated with CNS involvement in patients who underwent a diagnostic lumbar puncture. In the sensitivity analysis, we included additional control patients who did not undergo lumbar puncture, but were followed beyond 12 months without the development of CNS involvement in the absence of exposure to any fungicidal agents. RESULTS We entered 270 NHNT adult patients into the study during the 15-year period. CNS involvement was confirmed in 66 (71.0%) of 93 patients who underwent lumbar puncture. A multivariable analysis revealed that presence of neurological manifestations and elevated serum CRAG titers were independently associated with a 23.97-fold (95% confidence interval [CI], 4.37-182.23) and 1.53-fold (per 2-fold increment, 95% CI 1.26-1.92) increased odds ratio for CNS involvement, respectively. Headache and focal neurologic signs were independently associated with CNS involvement. A cut-off serum CRAG titer of ≥1:64 provided the highest diagnostic performance by Youden index (sensitivity 83% and specificity 65%). Similar findings were noted in the sensitivity analysis including 198 (73%) patients. CONCLUSION Lumbar puncture is indicated for NHNT patients with cryptococcosis who have neurologic manifestations or a serum CRAG titer of ≥1:64.
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Affiliation(s)
- Sung-Hsi Huang
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chien Lee
- Department of Internal Medicine, Fu Jen Catholic University Hospital, New Taipei, Taiwan
| | - Chien-Ching Hung
- Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jen Jen Su
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Pharmacy, National Taiwan University College of Medicine, Taipei, Taiwan
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147
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Ramanathan D, Sahasrabudhe N, Kim E. Disseminated Coccidioidomycosis to the Spine-Case Series and Review of Literature. Brain Sci 2019; 9:brainsci9070160. [PMID: 31284663 PMCID: PMC6680672 DOI: 10.3390/brainsci9070160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 12/24/2022] Open
Abstract
Coccidioidomycosis is a fungal infectious disease caused by the Coccidioides species endemic to Southwestern United States. Symptomatic patients typically present as community-acquired pneumonia. Uncommonly, in about 1% of infections, hematogenous extra pulmonary systemic dissemination involving skin, musculoskeletal system, and meninges occur. Disseminated spinal infection is treated with antifungal drugs and/or surgical treatment. A retrospective review of medical records at our institution was done between January 2009 to December 2018 and we present three cases of spinal coccidioidomycosis and review the current literature. Disseminated coccidioidomycosis can lead to spondylitis that can present as discitis or a localized spinal or paraspinal abscess. Spinal coccidioidomycosis is typically managed with antifungal treatments but can include surgical treatment in the setting poor response to medical therapy, intractable pain, presence of neurological deficits due to compression, or structural spinal instability.
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Affiliation(s)
| | | | - Esther Kim
- Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
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148
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Margaritopoulos GA, Kokosi MA, Wells AU. Diagnosing complications and co-morbidities of fibrotic interstitial lung disease. Expert Rev Respir Med 2019; 13:645-658. [PMID: 31215263 DOI: 10.1080/17476348.2019.1632196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Interstitial lung diseases (ILDs) represent a heterogeneous group of rare disorders that include more than 200 entities, mostly associated with high mortality. In recent years, the progress regarding the understanding of the pathogenesis of these diseases led to the approval of specific treatments. In ILDs, the presence of comorbidities has a significant impact on the quality of life and the survival of patients and, therefore, their diagnosis and treatment has a pivotal role in management and could improve overall outcome. Areas covered: We discuss key diagnostic issues with regard to the most frequent comorbidities in ILDs. Treatment options are also discussed as the decision to investigate more definitively in order to identify specific comorbidities (including lung cancer, pulmonary hypertension, GE reflux, and obstructive sleep apnoea) is critically dependent upon whether comorbidity-specific treatments are likely to be helpful in individual patients, judged on a case by case basis. Expert opinion: The extent to which clinicians proactively pursue the identification of comorbidities depends on realistic treatment goals in individual patients.
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Affiliation(s)
| | - Maria A Kokosi
- a Interstitial Lung Disease Unit , Royal Brompton Hospital , London , UK
| | - Athol U Wells
- a Interstitial Lung Disease Unit , Royal Brompton Hospital , London , UK
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149
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Bühler T, Medinger M, Bouitbir J, Krähenbühl S, Leuppi-Taegtmeyer A. Hepatotoxicity Due to Azole Antimycotic Agents in a HLA B*35:02-Positive Patient. Front Pharmacol 2019; 10:645. [PMID: 31244659 PMCID: PMC6580185 DOI: 10.3389/fphar.2019.00645] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/17/2019] [Indexed: 01/25/2023] Open
Abstract
We will present a 42-year-old woman with acute myeloid leukemia and pulmonary aspergillosis. She was treated with several antifungal agents, including three triazoles. Voriconazole, posaconazole, and isavuconazole all led to hepatocellular liver injury. Voriconazole administration led to a peak alanine aminotransferase (ALT) value of 1,793 U/L (normal range, 9–59 U/L). After posaconazole and isavuconazole treatment, ALT rose over 500 U/L. The typical course of events, exclusion of differential diagnoses, and normalization of the liver function tests (LFTs) after stopping the triazoles were highly suspicious for a drug-induced liver injury (DILI). Interestingly, our patient carries a rare HLA B allele (HLA B*35:02), which occurs in less than 1% of the population and is known to be associated with minocycline-induced liver injury. Over the course of 4 months, the patient received two induction chemotherapies and afterward underwent a successful allogenic hematopoietic stem cell transplantation. Her liver function recovered rapidly and favorable clinical findings concerning the aspergillosis led to a de-escalation of the antifungal treatment to prophylactic dose fluconazole. Delayed hepatotoxicity suggested a dose dependency and a cumulative effect. The question of a common pathophysiology and a cross-toxicity was raised. At the present time, only a few case reports describe cross-toxicity or its absence after rechallenge with different azoles. The pathophysiology is not well understood. Ketoconazole was found to impair rat mitochondrial function in vitro. Further investigations showed cell membrane toxicity and ATP depletion in isolated human liver cancer cells. Our case report suggests a cross-toxicity, dose-dependency, and a possible genetic predisposition of triazole-induced liver injury.
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Affiliation(s)
- Tim Bühler
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Michael Medinger
- Divisions of Hematology and Internal Medicine, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Jamal Bouitbir
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Stephan Krähenbühl
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Anne Leuppi-Taegtmeyer
- Department of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
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150
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Urabe N, Sakamoto S, Sano G, Ito A, Sekiguchi R, Homma S. Serial change in serum biomarkers during treatment of Non-HIV Pneumocystis pneumonia. J Infect Chemother 2019; 25:936-942. [PMID: 31186197 DOI: 10.1016/j.jiac.2019.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/08/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND For patients with non-human immunodeficiency virus (HIV) Pneumocystis pneumonia (PCP), data are limited on serial changes in serum biomarkers and the correlations with clinical outcomes. OBJECTIVE This study evaluated serial change in serum biomarkers and clinical outcomes of non-HIV PCP. METHODS We retrospectively reviewed data from 63 patients treated for non-HIV PCP at Toho University Omori Medical Center. The patients were classified as survivors and nonsurvivors on the basis of 60-day PCP mortality. The groups were compared for clinical course and levels of serum biomarkers (β-D glucan, Krebs von den Lungen-6 antigen [KL-6], and surfactant protein-D [SP-D]), which were measured at baseline, and 7 days and 14 days after starting treatment. In addition, serial changes in serum biomarkers were analyzed in survivors and nonsurvivors. RESULTS There were 14 PCP nonsurvivors and 49 survivors. Biomarker values were not different between groups at baseline. At 7 and 14 days after starting treatment, the proportions of patients with elevated β-D glucan and KL-6 did not significantly differ between groups; however, the proportion of patients with elevated SP-D was significantly lower among survivors than among nonsurvivors (57.1% vs. 100%, p = 0.009; 30% vs. 100%, p < 0.001; respectively). SP-D on day 14 was significantly lower than that at baseline among survivors (99.6 [61.0-190.3] vs. 156 [100.8-283.5]; p = 0.045) but significantly higher among nonsurvivors (974 [744.5-1565] vs. 317 [211-448]; p = 0.03). CONCLUSION Serum SP-D value continues to increase after failure of treatment for non-HIV PCP and may thus be associated with outcomes for non-HIV PCP patients.
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Affiliation(s)
- Naohisa Urabe
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan
| | - Susumu Sakamoto
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan.
| | - Go Sano
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan
| | - Ai Ito
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan
| | - Ryo Sekiguchi
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan
| | - Sakae Homma
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-nishi, Otaku, Tokyo 143-8540, Japan
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